Criteria for the ascertainment of death

The Italian Bioethics Committee (ICB) tackled the problem of the criteria used to declare human death. It is known that although death is only one, its diagnosis can today be ascertained with the traditional cardio-circulatory criterion (irreversible cessation of the circulatory and respiratory functions), as well as with the neurological criterion (irreversible cessation of all the functions of the brain, including those of the brain stem). Both these criteria have caused in the last few decades widespread scientific and ethical debate, also in consideration of the advancement of medical knowledge. The ICB has therefore deemed necessary to carry out a new and in depth discussion, capable also of integrating the document Definition and detection of human death, drafted by the same Committee in 1991.

In this document the ICB intentionally kept the problem of ascertaining death separate from that of organ transplants, on the basis of the precise premise that defining and ascertaining death must not have any ulterior motives, in the sense that we must always maintain the principle that declaring death is independent from the eventual removal of organs and from any utilitarian consideration relative to the social-healthcare costs of assisting post-anoxic patients. However, the Committee is aware that the link between them is now part of a widespread social feeling about this topic and that organ transplants, even in this document, must be taken into account especially when the issue is seen in a practical perspective.

After an ample clinical and ethical analysis, which took into account the different and divergent arguments, the ICB concluded that both neurological and cardio-pulmonary criteria are clinically and ethically valid to ascertain the death of an individual and completely avoid any chance of error.

In particular the Committee, with regards to the neurological criteria, believes that only those referring to the so-called “whole brain death” and “brainstem death” are acceptable, intended as an organic, irreparable brain damage, developed to an acute stage, which has caused a state of irreversible coma, where artificial support has intervened in time to prevent or treat an anoxic cardiac arrest. The Committee however believes that any explanations of this concept to the public should be corrected and updated especially with regards to terminology, with definitions that are more in line with current clinical practice.

The adopted criteria must also fulfil the condition of rigorously and meticulously respecting the clinical pre-requisites of the methodology, the procedures and the eventual use of verification tests. For this reason we recommend the highest possible uniformity in the protocols, both with regards to the cardio-pulmonary and the neurological criteria, which at the moment seem often different from country to country, causing confusion in public opinion with negative effects on the relative belief in the reliability of the criteria themselves.

In particular, the ICB’s criticism towards the definition of death by cardio-pulmonary criteria, focuses on those protocols, found in other countries, that establish very short times (between 2/5 minutes) to ascertain death. The risk is that the patient could still “be alive”, as the extremely short time elapsed from the cardiac arrest is insufficient to declare the irreversible loss of encephalic functions. The ICB stresses the importance of respecting the “dead donor rule” in the field of donations and in removing organs, which must not translate into “the dying donor rule”.